hipaa consent form emerson

Your Privacy is Important to Us

Acknowledgement of Receipt of Notice of Privacy Policies

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) such as: parents, or other family members or friends. (For minors, please list anyone we can speak with other than the custodial parents or legal guardians.)

Name

Phone #

Date

Name

Phone #

Date

Name

Phone #

Date

Name

Phone #

Date

Name

Phone #

Date

I hereby acknowledge that a copy of the Notice of Privacy Practice of Emerson Dental has been made available to me. I hereby authorize, as indicated by my signature below, to use and to disclose, my protected health information for any necessary clinical, financial, and insurance purposes, as authorized in the Patient Consent Form.

NOTICE OF PRIVACY PRACTICES

First Name

Last Name

Address

Signature of Patient (or legal guardian)

Clear

Clear

Date

Online Signature×

Draw your signature inside the box Clear